Underlying causes of ovulatory dysfunction, such as thyroid dysfunction, should be corrected if possible. As with men, women who have hyperprolactinemia can be treated with dopaminergic agents, which may restore ovulation. Insulin-sensitizing agents, most commonly metformin (Glucophage), have been shown to increase ovulation and pregnancy rates in patients with PCOS, although these agents are not yet approved by the U.S. Food and Drug Administration (FDA) for the treatment of infertility. Laparoscopic ovarian drilling for ovulation induction also may be considered for patients with PCOS if other treatments are unsuccessful.

In most women with ovulatory dysfunction without evident cause or that is not otherwise correctable, the condition can be managed with use of the oral ovulation-inducing agent clomiphene citrate. Clomiphene citrate can be used in patients with PCOS as well, with or without the coadministration of insulin-sensitizing agents. Treatment with clomiphene citrate is ineffective in patients with ovulatory dysfunction caused by hypothalamic amenorrhea, however, because its mechanism of action occurs at the hypothalamus. These patients are more likely to respond to gonadotropin therapy. Women with limited ovarian reserve also are unlikely to benefit from ovulation induction. Currently, only oocyte donation has been proven successful for these patients.

Clomiphene citrate is generally well tolerated and effective; 80 percent of appropriately selected patients will ovulate with this treatment. Major risks associated with the use of clomiphene citrate include ovarian hyperstimulation syndrome and twinning. Higher-order multiple gestation is a rare consequence. Generally, a dosage of 50 mg per day is administered starting on day 3 to day 5 of the menstrual cycle and is continued for five days. Documentation of ovulation can be accomplished fairly easily with basal body temperature charting or use of a urinary LH kit. If a dosage of 50 mg per day is insufficient to induce ovulation, it can be increased to 100 mg per day.

Higher dosages generally should be managed by a fertility specialist because 100 mg per day is the maximal dosage approved by the FDA. If clomiphene citrate therapy is unsuccessful, additional treatment options include IVF and injectable ovulation-inducing agents such as human menopausal gonadotropin, exogenous FSH, and gonadotropin-releasing hormone.

Management of tubal, uterine, and pelvic disease

Tubal disease may be treated with tubal reparative surgery, although success rates are generally low and are compromised by increased risk of subsequent ectopic pregnancy. IVF is an alternative, especially in patients with markedly damaged tubes. Patients with endometriosis may benefit from laparoscopic ablation or laparotomy, depending on the severity of disease. Ovulation induction with or without intrauterine insemination and IVF also can be used in these patients.

Management of unexplained or persistent infertility

Options for patients with unexplained infertility include intrauterine insemination, clomiphene citrate therapy, and intrauterine insemination with either clomiphene citrate or gonadotropin therapy. To date, the benefit of IVF has not been proven in patients with unexplained infertility. IVF may be useful in patients with persistent infertility in whom treatments for specific diagnoses have been unsuccessful.

Third-party reproduction

Donor sperm (IUI)

Donor egg (IVF)

Donor embryo (IVF)

Gestational Carrier (IVF)

How long must a couple have been having unprotected sex to be considered infertile?

Increase in minute ventilation due to rise in tidal volume – more tthan oxygen consumption of maternal tissues → hyperventilation (thought to be due to progesterone and protective for fetus respiratory control)

Not the same symptoms, check urine every visit, culture if frequent before pregnancy

Pyelonephritis can be an issue

Rh factor

type and screen

if negative give Rogan anytime there is a significant bleed

again at 28 weeks and once baby is born

Surgical history

scar tissue

Cervix? Could be incompetent

C-section:

controversial

@ Duke: one, you can have a vaginal birth next time; 2-3 c-section always

Pregnancy and Family hx

Htn

Diabetes

Cancer

Pregnancy and Social history

Smoke: #1 cause of pre term labor

Drugs: there will be a drug screen done at labor which can get social work involved if in the chart it states a history of drug use. Cocaine (abruption of placenta)

Support system: planned?

Abuse: increases during pregnancy

Seatbelt use: need to use it low

Gun safety

Medications

Aspirin not used during pregnancy

Can take Tylenol NOT Ibuprofen

Management of N/V During Pregnancy

Ginger ale, lemonade, salty things

Small frequent meals

Empty stomach makes it worse

B6 vitamins

BRAT diet

Meds: Zofran, Phenergan (sleepiness), Reglan (h/a)

Usually goes away 12-14 weeks

Hyperemesis gravida: look into social hx, abuse

Hemolytic disease of the newborn (erythroblastosis fetalis)

mom is Rh – and baby is Rh + for first pregnancy. Mom is given Rh immune globulin within 72 hours of delivery so she won’t produce anti-Rh, preventing erythroblastosis with her next pregnancy. Immune globulin also administered at 28 weeks

Centering Pregnancy provides group prenatal care that is relationship centered, nurturing and transforming relationships among women, their families, and health care professionals. Complete prenatal care is provided in a group setting. Prenatal assessment, education, and support occur in a facilitative environment. The model offers effective and efficient care that is sustainable and can enhance the health of women, their families, health care providers, and communities.

“In utero Apgar

Fetal breathing

Fetal movement

Fetal tone

Amniotic Fluid

Non Stress Test

Rh

Rh immune globulin administered within 72 hours after delivery

The antibodies in the immune globulin destroy fetal Rh-positive cells so that the mother will not produce anti-Rh

Routine administration of immune globulin at 28th week of pregnancy

Assessing Fetal Lung

All tests involve amniotic fluid, which is an indirect assessment of the likelihood of lung maturity; direct studies of fetal pulmonary function are not possible.

In term and near term gestations, amniocentesis is used as an assessment of fetal lung maturity. Although only one factor in the final pre-delivery development of the term newborn

AmnioStat-FLM: This test looks for the presence of a lung surfactant called phosphatidylglycerol (usually just called PG). This is an agglutination test that uses antibodies to detect PG in amniotic fluid. If PG is present then visible agglutinates (clumps of particles) can be seen and the fetal lungs are considered mature.

Lamellar Body Count: In certain cells of the lungs, surfactants are packaged into granules called lamellar bodies and secreted from the cells into the alveoli. This test actually counts the number of lamellar bodies in amniotic fluid. The higher the lamellar body count, the more likely it is that the fetal lungs are mature.

Lecithin/Sphingomyelin Ratio: This was the first test of fetal lung maturity ever developed and is more commonly known as the L/S ratio. It's a measure of the ratio of two lung surfactants, lecithin and sphingomyeli, that's determined using a technique known as thin-layer chromatography. Lecithin is the most important lung surfactant and provides the greatest surface tension-lowering properties of all the surfactants. It increases dramatically in the last few weeks of pregnancy. Sphingomyelin is a minor lung surfactant and that amount of it in the lungs stays about the same throughout pregnancy so it serves as a good baseline against which the increasing amount of lecithin can be compared. A ratio that is 2.5 or greater is usually used to indicate lung maturity. Many doctors consider this to be the "best" fetal lung maturity test but that is not true.

TDx FLM II: This test measures the ratio of surfactant to albumin and so is sometimes called the S/A ratio.

The test relies on a technique known as fluorescence polarization and is the most widely used fetal lung maturity test; unfortunately it will no longer be available to clinical labs at the end of this year because the manufacturer has decided to stop making it. The effect that the loss of this test will have on patients, doctors, and labs remains to be seen!

Leopold maneuvers

First maneuver (Upper Pole): stand at woman’s side, facing her head. Keeping the fingers of both examining hands together, palpate gently with the fingertips to determine what part of the fetus is in the upper pole of the uterine fundus

Second maneuver (Sides of the maternal abdomen): place one hand on each side of the woman’s abdomen, aiming to capture the body of the fetus between them. Use one hand to steady the uterus and the other to palpate the fetus.

Third Maneuver (Lower Pole): Turn and face the woman’s feet. Using the flat palmar surfaces of the fingers of both hands and, at the start, touching the fingertips together, palpate the area just above the symphysis pubis. Note whether the hands diverge with downward pressure or stay together. This tells you whether or not the presenting part of the fetus—head or buttocks—is descending into the pelvic inlet.

Fourth Maneuver (Confirmation of the Presenting Part): with your dominant hand, grasp the part of the fetus in the lower pole, and with your nondominant hand, the part of the fetus in the upper pole. With this maneuver, you may be able to distinguish between the head and the buttocks

Smoking

Remains the single most important preventable cause of poor birth outcome

20% low birth weight deliveries

8% pre-term births

5% perinatal deaths

Reasons for Reduced Fetal Growth

Lower maternal weight gain

Vasoconstriction and decreased uterine blood flow

Carbon monoxide toxicity

Increased cyanide production

Fetal Heart Rate Monitoring

Non Stress Test

FHR accelerations 15 beats x 15 seconds x2 in 20 minutes

Biophysical Profile

Labor

Diabetes

Who needs a GCT?

Risks of Diabetes Mellitus

congenital anomalies

risk of preterm birth (IUGR, polyhydramnios)

Abnormal fetal growth (IUGR, macrosomia)

PIH (25% incidence)

Spontaneous abortion

A pregnancy that ends spontaneously before the fetus has reached a viable gestational age.

Expectant management if <13 weeks, stable vital signs, no evidence of infection (This is based on UpToDate, and differs from book, which states regarding watchful waiting of incomplete AB: “Conservative management of these patients significantly increases the risk of infection.” )

Tubal abortion: expulsion of POC through the fimbria, resulting in tissue regression or reimplantation (abdominal or ovarian)

Spontaneous resolution (1955 study 48%)

Gestational Trophoblastic Neoplasia (GTN)

A rare variant of pregnancy

Hydatidiform mole (complete and partial)

Invasive mole (chorioadenoma destruens)

Choriocarcinoma

Placental-site trophoblastic tumor (PSTT)

Clinical Features: Usually benign molar pregnancy. Potential for malignant transformation (choriocarcinoma). Often exaggerated pregnancy symptoms. Now more often diagnosed before clinical manifestations, due to hCG and U/S. hCG is the tumor marker – quantitative counts will be much higher than expected. Highly curable with chemotherapy.

Evaluation: hCG, U/S, Workup for metastatic disease

Treatment: D & C, Methotrexate, Other chemotherapeutic agents, if malignant or malignant potential. Follow with serial hCGs. Make sure levels return to zero. If they don’t come back or are increasing – could be GTN.

Cervical Insufficiency

previously cervical incompetence

Painless cervical changes that occur in the second trimester and result in recurrent pregnancy loss

Eugenics: Some believe that testing is available to eliminate certain genetic conditions or groups of people

Privacy/confidentiality/discrimination: Who should have access to results?

Effective patient and public education

non-directive counseling

Nondirective, or client-centered, counseling is the process of skillfully listening to a counselee, encouraging the person to explain bothersome problems, and helping him or her to understand those problems and determine courses of action. This type of counseling focuses on the member, rather than on the counselor as a judge and advisor; hence, it is “client-centered.”

It stresses changing the person, instead of dealing only with the immediate problem in the usual manner of directive counseling. The counselor attempts to ask discerning questions, restate ideas, clarify feelings, and attempts to understand why these feelings exist.

Counseling procedure in which the counselor is empathetic and does not evaluate or direct (but may clarify) clients' remarks, thus assisting them to accept responsibility for their own problem-solving.

The non-directive approach involves presentation of the facts in an unbiased manner, leaving the entire responsibility of decision with the consultee. It supports people in reaching their own decisions, based on their own unique medical and social circumstances.

ACOG: Individuals of African, Southeast Asian, and Mediterranean descent are at increased risk of being carriers of hemoglobinopathies and should be offered screening tests. If both parents are carriers, genetic counseling should be available. A complete blood count and hemoglobin electrophoresis or HPLC are appropriate screening tests.

Current ACOG recommendations for cystic fibrosis (CF) screening.

As a routine part of obstetric care and regardless of ethnicity, all women of reproductive age should be offered preconception and prenatal CF carrier screening.

CF screening should be offered to all women of reproductive age, although it is most efficacious in the non-Hispanic white and Ashkenazi Jewish populations.

If a patient has been screened previously, the test should not be repeated, but CF screening results should be documented.

For routine carrier screening, complete analysis of the CF transmembrane regulator (CFTR) gene by DNA sequencing is not appropriate.

Maternal carrier screening is not replaced by newborn screening panels that include CF screening.

If a woman with CF wishes to become pregnant, a multidisciplinary team may assist in management of issues regarding pulmonary function, weight gain, infections, and higher risks for diabetes and preterm delivery.

When both parents are CF carriers, they should undergo genetic counseling to review prenatal testing and reproductive options.

When neither parent is affected by CF, but 1 or both has a family history of CF, CFTR mutation analysis in the affected family member may be identified from medical record review, and the couple should undergo genetic counseling.

If a woman's reproductive partner has CF or apparently isolated congenital bilateral absence of the vas deferens, mutation analysis and consultation by a geneticist is recommended.

Originally designed to test for conditions that could not be determined by CVS or amnio alone. Currently used to evaluate fetuses at risk for thrombocytopenia, etc and used for management issues (i.e., transfusion)

Fluorescent In Situ Hybridization (FISH)

Fluorescent probes used to adhere to centromeric region of chromosomes

Allows for a rapid, preliminary result of certain aneuploidy

Can identify conditions associated with small deletions of chromosomes (i.e., Prader-Willi syndrome)

Hyperventilation, as a result of increased tidal volume, results in mild respiratory alkalosis

May be feto-protective to prevent fetus from being exposed to high CO2 tensions

Pregnancy Changes Renal system

Anatomic changes

Length of kidneys increase by 1/5cm

Entire collecting system dilates to contain ~200ml more urine; disappears by postpartum day 4

Pregnancy Changes Renal function

Renal plasma flow increases 50-85%, results in:

Elevated GFR - peaks by end of 1st trimester and remains high until term

Lowers Cr and BUN serum concentrations

Decreased renal vascular resistance

Renin activity increases in 1st trimester and rises until term

Pregnant women are resistant to vasoconstriction effects of angiotensin II and other vasopressors

Pregnant women who are unable to sufficiently augment vasopressin secretion (in the presence of vasopressinase produced by placenta) can develop a diabetes insipidus–like condition characterized by massive diuresis and profound hypernatremia

Pregnancy Changes Bladder

Displaced upward as uterine enlarges

Increased urinary frequency

Increased bladder capacity

Pregnancy Changes GI system

Anatomic changes

Abdominal organs displaced with uterine growth

Pregnancy Changes Oral cavity

Increased salivation

Hypertrophic gums with easy bleeding, possibly due to increased estrogen

Pregnancy Changes Esophagus and stomach

Reflux symptoms in ~80% of women, commonly in 1st trimester

Greater production of gastrin → increased stomach volume and acid production

Decreased peristalsis

Slowed gastric emptying of solid foods

Pregnancy Changes Intestines

Decreased transit times (slower) in 2nd and 3rd trimesters, due to progesterone?

Can enhance water absorption and predispose to constipation

Pregnancy Changes Gallbladder

Slowed/incomplete emptying

Increased risk of stone formation

Pregnancy Changes Liver

Reduced plasma albumin levels

Elevated serum alkaline phosphatase

Pregnancy Changes Hematologic system

Pregnancy Changes RBCs

Cell mass expansion by 33% → anemia

Pregnancy Changes Iron

Many women begin pregnancy in an iron-deficient state, making them vulnerable to iron deficiency anemia → supplemental iron

The maternal appetite and food intake usually increase, although some have a decreased appetite or experience nausea and vomiting. In rare instances, women with pica may crave substances such as clay, cornstarch, soap, or even coal

Pregnancy and STIs

Syphilis: Penicillin remains the treatment of choice in pregnancy, secondary to its ability to cross the placenta and treat the fetus

For PCN allergic pts: penicillin desensitization is recommended

Chlamydia: Treatment usually consists of 7 days of erythromycin or one dose of azithromycin in the pregnant woman

Gonorrhea: ceftriaxone is the drug of choice

HSV: Oral acyclovir may be used for recurrent outbreaks and should be considered after 36 weeks for prophylaxis against outbreaks at the time of delivery. Cesarean delivery is the route of choice for patients with active lesions. High rate of morbidity and mortality associated with neonatal herpes infection

HIV: The goal of prenatal care for HIV-positive pregnant women focuses on appropriately treating maternal disease and minimizing vertical transmission of HIV. Pharmacotherapy varies, but usually consists of regimen of highly active anti-retroviral therapy (HAART) and intrapartum infusion of azidothymidine (AZT). Cesarean delivery is recommended only for patients with high viral load

Trichomoniasis: discharge is fetid, foamy, or greenish, or when there are reddish ("strawberry") petechiae on the mucous membranes of the cervix or vagina

Candidiasis: vaginal burning and itching and a profuse, caseous, white discharge. Topical miconazole nitrate or nystatin suppositories are the preferred treatment during pregnancy

BV: 2-fold increased risk of preterm birth in general

Pregnancy Issues

UTI: pregnant women are susceptible. Not the same symptoms, check urine every visit, culture if frequent before pregnancy. Pyelonephritis can be an issue

Rh factor: type and screen, if negative give Rogan anytime there is a significant bleed, at 28 weeks and once baby is born

Intercourse: if cramps or spotting follow coitus, it should be proscribed for the time being. Coitus late in pregnancy may initiate labor

Bathing: Water does not enter the vagina, bathing or swimming is not contraindicated

Douching: May be harmful

Dental care: Periodontal disease has been associated with an increased risk of preterm birth

Immunizations: Killed virus, toxoid, or recombinant vaccines may be safely administered during pregnancy, and patients should be vaccinated appropriately for both maternal and fetal benefit. Live, attenuated vaccines, including those for varicella, measles, mumps, polio, and rubella, should be given 3 months prior to pregnancy or immediately postpartum. These vaccines are contraindicated in pregnancy secondary to the potential of fetal infection

Employment

Travel: instruct patients with a history of spontaneous abortion and those who have experienced vaginal bleeding in the course of the present pregnancy to avoid travel to distant places

What is adequate labor?

Classically, 3-5 ctx’s in 10 min (seen in 95%)

IUPC, 200 to 250 Montevideo units

Fetal variables that influence course of labor

Size: macrosomia (4,500 g)

Lie: longitudinal axis of fetus to uterus

Presentation: vertex, breech, shoulder, compound

Position: relationship of presenting part in relation to the pelvis

Station: measure of descend through birth canal

True vs False (Braxton Hicks) labor

Before "true" labor begins, you may have "false" labor pains, also known as Braxton Hicks contractions. These irregular uterine contractions are perfectly normal and may start to occur as early as the second trimester, although they are more common during the third trimester of pregnancy. They are your body's way of getting ready for the "real thing."

What Do Braxton Hicks Contractions Feel Like?

Braxton Hicks contractions can be described as tightening in the abdomen that comes and goes. These contractions are typically not painful and do not occur at regular intervals. They do not get closer together, do not increase with walking, do not increase in how long they last, and do not feel stronger over time as they do when you are in true labor.

What Do True Labor Contractions Feel Like?

The way a true labor contraction feels is different for each woman and may feel different from one pregnancy to the next. Labor contractions cause discomfort or a dull ache in your back and/or lower abdomen, along with pressure in the pelvis. Some women may also feel pain in their sides and thighs. Some women describe contractions as strong menstrual cramps, while others describe them as strong waves that feel like diarrhea cramps.

False Labor

Contractions are often irregular and do not get closer together

Contractions may stop when you walk or rest, or may even stop if you change positions

Contractions are usually weak and do not get much stronger. Or they may be strong at first and then get weaker.

Contractions are usually only felt in the front of the abdomen or pelvic region

True Labor

Contractions come at regular intervals and last about 30-70 seconds. As time goes on, they get closer together.

Contractions continue despite movement or changing positions

Contractions steadily increase in strength

Contractions usually start in the lower back and move to the front of the abdomen

lightening

the settling of fetal head into the brim of the pelvis – occurs 2 or more weeks before labor in primigravida women

often accompanied by increased pelvic discomfort and urinary frequency

several days to weeks before onset of true labor, cervix begins to soften, efface, and dilate

With cervical effacement, the mucus plug within the cervical canal may be released

the onset of labor is sometimes marked by the passage of a small amount of blood-tinged mucus from the vagina known as bloody show

Fetal Lie

Longitudinal axis of fetus to the longitudinal axis of uterus

Transverse

Oblique

Longitudinal

Effacement

Thinning of the cervix

Station and Presentation

Vertex

Breach

Shoulder

Compound

Cardinal movements of labor

Engagement: passage of widest diameter of presenting part to the below plane of the pelvis. The head enters the superior straight in the occiput transverse position ~70% of women with gynecoid pelvis. Usually occurs late in pregnancy, commonly last 2 weeks.

Descent: downward passage of presenting part through the pelvis. Affected by the forces of labor and thinning of the lower uterine segment. The greater the pelvic resistance or the poorer the contractions the slower the descent.

Flexion: passive flexion of fetal head as it descend due to resistance related to body pelvis

Internal rotation: rotation of presenting part (usually from transverse to anterior-posterior). Rotation occurs so that the sagittal suture occupies the A-P diameter of the pelvis. Normally begins when the presenting part is at the level of the ischial spines.

Extension: brings base of occiput in contact with the inferior margin of the pubic symphysis. Head is delivered by extension. Crowning occurs when the largest diameter of the fetal head is encircled by the vulvar ring. Further extension follows extrusion of the head beyond the introitus.

External rotation (restitution): rotation to the correct anatomic position in relation to the fetal torso. Follows delivery of the head. Followed by delivery of the shoulders.

Expulsion: delivery of body of fetus

First Stage of Labor

The first phase of the first stage of labor is called the latent phase, when contractions are becoming more frequent (usually 5 to 20 minutes apart) and somewhat stronger. However, discomfort is minimal. The cervix dilates (opens approximately three or four centimeters) and effaces (thins out). Some women may not recognize that they are labor if their contractions are mild and irregular.

The latent phase is usually the longest and least intense phase of labor. The mother-to-be is usually admitted to the hospital during this phase. Pelvic exams are performed to determine the dilatation of the cervix.

The second phase of the first stage (active phase) is signaled by the dilatation of the cervix from 4 to 7 centimeters. Contractions become longer, more severe, and more frequent (usually 3 to 4 minutes apart).

The third phase is called transition and is the last phase. During transition, the cervix dilates from 8 to 10 centimeters. Contractions are usually very strong, lasting 60 to 90 seconds and occurring every few minutes. Most women feel the urge to push during this phase.

In most cases, the active and transition phases are shorter than the latent phase.

Second Stage of Labor

The second stage of labor begins when the cervix is completely opened and ends with the delivery of the baby. The second stage is often referred to as the "pushing" stage. During the second stage, the woman becomes actively involved by pushing the baby through the birth canal to the outside world. When the baby's head is visible at the opening of the vagina, it is called "crowning." The second stage is shorter than the first stage, and may take between 30 minutes to two hours for a woman's first pregnancy.

Third Stage of Labor

After the baby is delivered, the new mother enters the third and final stage of labor - delivery of the placenta (the organ that has nourished the baby inside of the uterus). This stage usually lasts just a few minutes and involves the passage of the placenta out of the uterus and through the vagina.

Initial labor assessment

Time of onset and frequency of contractions, status of membranes, any history of bleeding, and any fetal movement.

History of allergies, use of medication, and time, amount, and content of last oral intake.

Status of the membranes, cervical dilatation and effacement (unless contraindicated, eg, by placenta previa), and station of the presenting part

When a patient is admitted, a hematocrit or hemoglobin measurement should be obtained and a blood clot should be obtained in the event that a cross-match is needed. A blood group, Rh type, and antibody screen should also be done.

Passenger: Fetal variables that influence the course of labor

Size - macrosomia (4,500 g)

Lie - longitudinal axis of fetus to uterus

Presentation - vertex, breech, shoulder, compound

Position - relationship of presenting part in relation to the pelvis

Station - measure of descend through birth canal

How to assess contractions

Qualitatively: Observation of the mother and palpation of the fundus of the uterus. External tocodynamometry (Toco). Number of contractions in an average 10 min window, intensity, and duration of the contractions

Mild contractions begin at 15 to 20 minutes apart and last 60 to 90 seconds. The contractions become more regular until they are less than 5 minutes apart. This part of labor is called the Latent Phase

When the cervix dilates from 4 to 8 centimeters (called the Active Phase), contractions get stronger and are about 3 minutes apart, lasting about 45 seconds

When the cervix dilates from 8 to 10 centimeters contractions are 2 to 3 minutes apart and last about 1 minute

Dystocia of Labor

characterized by the slow, abnormal progression of labor

leading indication of primary c-section

1 in every 10 birth (U.S.) has had a c-section

60% of ALL c-sections in the US are attributable to the diagnosis of dystocia

Leading cause of developmental disability in children, including cerebral palsy and mental retardation.

Important cause of blindness and chronic lung problems

Cause of Preterm

Epidemiological studies have identified potential risk factors

Smoking

African American

Maternal age: youngest and oldest

Stressful social factors: poverty, poor housing, crime

Underlying biological mechanisms poorly understood

It has been recognized that “silent” infections, such as vaginal infections or periodontal gum disease. However, data from treatment of infections may not be effective in preventing preterm delivery. Perhaps the inflammatory response to infection, and not the infection itself, is responsible for preterm delivery

Stillbirth occurs frequently (10–15%) if delivery is not prompt; neonatal loss is high (20–25%), usually because of prematurity (see Chapter 19).

Corticosteroids may hasten recovery in HELLP syndrome.

HELLP syndrome occasionally persists beyond 2–3 days postpartum, in which case it takes on the characteristics of other microangiopathic hemolytic disorders, such as thrombotic thrombocytopenic purpura or hemolytic-uremic syndrome.

Plasmapheresis may be required with persistent HELLP syndrome.

Puerperium

The 6 to 8 week period after birth during which the reproductive tract returns to its normal, nonpregnant state. (Often defined as 42 days)

Contraction of the uterus is the major mechanism to prevent hemorrhage

By 24 hours after delivery, fundus is near umbilicus

One week after delivery, fundus is between symphysis & umbilicus

Uterus returns to the pelvis by 2 weeks postpartum

Uterus nearly normal size by 6-8 weeks postpartum

In many women, the uterus never completely returns to its pre-pregnancy size.

Often find the uterus to be enlarged to a 6-8 weeks pregnant size at the 6-8 week postpartum exam

Return of ovarian function postpartum

Ovulation suppression is due to high prolactin levels, which remain elevated until approximately 3 weeks after delivery in nonlactating women and 6 weeks in lactating women

When not breastfeeding: Ovulation can occur as early as 4 to 5 weeks postpartum if not breastfeeding. Mean time 45 days. 50% of women ovulate by 90 days postpartum. Estrogen levels begin to rise in 2 weeks. Return of menses in 7-9 weeks. Discuss contraceptive methods

When breastfeeding: Time to first ovulation dependent on breastfeeding practices. When exclusive with breastfeeding – most women can remain amenorrheic for 6 months and is about 98% effective as contraceptive method. Ovulation suppressed due to prolactin. Estrogen levels low. Hypoestrogenic state due to suppression of ovarian function (like menopause). Loss of vaginal rugation. Vaginal dryness. Menstruation returns as late as 36 months in 70% of breastfeeding mothers.

Onset: Symptoms peak about the 4th – 5th day after delivery and typically subside by the 10th day.

Treatment: Time – may last a few days to 2-3 weeks. Support of Friends and Family

Up to 20% of women who suffer from this disorder will go on to develop depression in the first postpartum year

Postpartum depression

Prevalence: 10–20% postpartum. The syndrome is profoundly under diagnosed (< 15%) and often left untreated

Risk factors: Marital tension. Highest risk were women whose spouses were rated “low” in caring or who were rated as over-controlling. Financial problems. Low levels of social support. Negative life stress during pregnancy and the postpartum, particularly a move or the loss of a loved one. Difficult infants; temperament/health problems. History of depression or other psychiatric illness, including prior pregnancy-associated depression. (Yet most women with a history of depression do not become depressed). A mother who had postpartum depression. A troubled childhood with little love. Poor self-esteem as an adult – high interpersonal sensitivity. An unsupportive extended family. Women with complications during pregnancy are three times more likely to suffer from postpartum depression.

Symptoms: Depressed mood with clear evidence that the symptoms are substantially interfering with functioning.

At least four of the following: Appetite disturbance, Sleep disturbance, Agitation or psychomotor retardation, Loss of interest, Loss of libido, Fatigue, Self-deprecation or guilt, Difficulty with concentration, Suicidal ideation, May involve fear of harming infant

Severity: Estimates are that half of these suffer from a minor, as opposed to a major, depression – less suicidal ideation, more guilt, agitation, and irritability

Onset: the syndrome develops weeks to months after delivery when the patient is not under the routine medical care

Treatment: Dependent on severity of symptoms. Support from family & friends. Psychotherapy, antidepressant medication. Professional assessment strongly recommended. Support groups

Postpartum psychosis

Psychosis is a severe mental illness characterized by a false reality and can be associated with fear and impulsivity

Prevalence: 1 to 2 births per 1000. In one study - ¾ of cases of postpartum psychosis occurred after the birth of the first child

Risk factors: Previous episode of psychosis (Especially, postpartum psychosis), Bi-polar affective disorder, Family history of bi-polar affective disorder or postpartum depression., Marital and family problems, Recent stressful life situations, Lack of social supports

Symptoms: restless, unable to sleep, irritable, have pressured speech, unusual behavior, obsessional or delusional thinking, or become very withdrawn

Severity: severe – a medical emergency

Onset: typically within several days to 2-4weeks postpartum. Early onset and lucid intervals may be confused with “baby blues”; 75% of admissions within the first two weeks.

Treatment: skilled professional intervention, admission to hospital for delusions and the concern that the woman may harm herself or the infant